The Wrist and Hand

From little fingers getting stuck in doors, to bigger fingers being bent back by baseballs, the hand and wrist are frequent sites for acute (occuring suddenly during activity) injuries and overuse problems.

Hand and wrist anatomy

The hand and wrist are made up of many bones

  • Phalanges: Better known as the fingers or digits. There are typically five digits on each hand, although people can be born with four or six. The thumb has two phalangeal bones (proximal and distal phalanx), while each of the other fingers have three phalangeal bones (proximal, middle and distal phalanx). The finger nail is located on the distal phalanx.
  • Metacarpals: The metacarpal bones represent the middle portion of the hand in between the fingers (phalanges) and wrist. There are five metacarpal bones, and they are typically numbered one (thumb) to five (pinky finger).
  • Carpal bones: There are a total of eight carpal bones. They are less frequently involved in acute injuries, except for the scaphoid bone, which is located between the thumb and the forearm.

Hand Injuries

We often see injuries to the hand in children and adolescents. Some common injuries include: 

Boxer's fracture

A boxer's fracture is an injury to the knuckle of the fourth or fifth (ring or little) finger of the hand. These fractures occur when a person strikes (punches) a hard object with a closed fist. Most of these injuries may be treated with a cast or splint for four to six weeks on average, although some may require surgery when the bone is significantly angulated.

Finger dislocation

Finger dislocations can occur at any of the three joints along the finger including the metacarpophalangeal (MCP) joint, the proximal interphalangeal (PIP) joint or the distal interphalangeal (DIP) joint. All dislocations will require the finger to be set or put back in place. As these dislocations are relatively common in sports, this can even be done right there on the field. However, you should consult with an orthopaedic doctor to evaluate your child’s injury further.

After the injured finger is set, it will either be placed in a cast or buddy taped for an average of four to six weeks. As with most finger injuries, mild swelling and soreness may continue for several months. Depending on what your doctor recommends, your child will likely be able to return quickly to their sport.

Mallet finger

Commonly referred to as a mallet finger, this injury is caused by a direct blow to the tip of a finger. It occurs when a ball is being caught, hits an outstretched finger and forcefully flexes is downward, tearing the extensor digitorum tendon.

Often, these injuries may be treated with a finger splint called a stack splint, which must be worn 100 percent of the time for six to eight weeks while the tendon is reattaching. If the finger flexes, even only for a moment, then the entire treatment must begin again. Despite its extensive treatment, the majority of these injuries heal without surgery.

Metacarpal fractures

Metacarpal fractures are characterized as articular (joint) vs. extra-articular (not involving the joint) and by location (base, shaft, neck or head). Angular deformity (crookedness) may be accepted up to a point, depending on which finger is involved, but not if it impairs movement. Typically, fractures of the fourth and fifth metacarpals can be left crooked because there is increased flexibility in this area.

Diagnosis is made with the physical exam along with an X-ray.

Treatment is usually a cast or splint immobilization for two to three weeks. Surgery may be recommended if the fingers are not properly aligned, movement is impaired, the fracture is open (compound), the joint is displaced or if the fracture is unable to be controlled by casting.

Thumb fracture

With a broken thumb, you will usually have pain and will notice bruising in the area. X-rays are used to confirm the diagnosis. Treatment involves either setting the thumb (with or without pins) or merely immobilizing it with casting. Healing typically takes around six weeks.

A gamekeeper’s thumb is another term for a sprain of the ulnar collateral ligament (UCL) at the base of the thumb. These injuries often occur when an athlete falls or catches his thumb on an object and forcibly pulls the thumb in the opposite direction. These sprains can require splinting, braces and sometimes even casting. If the ligament tears completely (skier’s thumb) then a more extensive workup and treatment plan will be needed, sometimes requiring surgery.

Thumb fracture

Wrist Injuries

We often see injuries to the wrist in children and adolescents. Some common injuries include:

Gymnast wrist

As the name implies, gymnast wrist is an overuse injury to the growth area of the radius bone near the wrist. It occurs in up to 40 percent of gymnasts, and is caused by the enormous pressure placed on a backward bent wrist (dorsiflexed) while vaulting or tumbling. Symptoms include wrist pain with impact activities. This injury can sometimes be seen on X-rays, but typically the diagnosis is made from clinical history and physical exam.

Treatment involves a period of rest to allow the growth area to heal. Wrist braces, such as tiger paws are particularly helpful with the symptoms. Return to activities can happen when symptoms subside.

Ulnar impaction syndrome

Ulnar impaction is one of the many causes of ulnar (pinky-sided) wrist pain and is typically a result of excessive loading of the wrist. X-rays are useful in the diagnosis, especially when comparing the injury to the other side. Treatment often means bracing, injections and physical therapy. Surgery is reserved for cases where other non-operative treatment fails.

As with any childhood overuse injury, it’s highly recommended that young athletes take at least three to four months off per year from any one particular sport to allow for recuperation and healing. It’s generally safe for young athletes to play multiple sports throughout the year, but a variety of activities is key to healthy bones and muscles.

Wrist fractures

Buckle and greenstick fractures

Another type of pediatric fracture is a buckle (or torus) fracture. These fractures are the result of an injury to a bone that’s softer and less calcified than adult bones. Imagine this injury is similar to the motion of forcing two ends of a piece of paper together, causing a crinkling, or buckling of the paper.

Luckily, these buckle fractures are not as painful and they heal quickly with few long-term effects. Often, the only necessary treatment is a cast for three to four weeks.

A variation of a buckle fracture is a greenstick fracture. This, as the name implies, is a fracture of a young bone that is like the bending of a young (still green on the inside) tree limb. Here the bone does not break into two pieces, but it bends remaining intact on the inside and fractures on the outside of the curve.

Although these fractures are called wrist fractures, this is a misleading term as the bone really breaks at the end of the forearm bones near the wrist joint. The bones are called the radius and the ulna. The radius is on the side of the thumb while the ulna is on the side of the pinky. These bones break in one of three ways:

  1. Both bones break away from the growth plate
  2. One or both bones break within the growth plate
  3. One or both bones buckle in a relatively weaker part of the bone

If the bone breaks away from the growth plate, the pieces are often separated far from each other and may need to be put back into place under sedation. Typically, once the pieces are lined up, your child will be placed in a cast that goes above the elbow for a month, and then a shorter cast for several more weeks. At first, weekly office visits may be necessary until the fracture heals enough that the bone won’t move in the cast. Once the casting is done, your child may be prescribed a wrist brace to wear for several weeks for extra support.

If the bone breaks within the growth area, your child’s doctor will line up the bones as straight as possible. While treatment is much like what’s described above, a follow-up visit may be necessary six months after the fracture to ensure the bone is growing normally.

Sprains and strains

Wrist strains and sprains are common sports injuries and occur when an athlete attempts to break a fall with outstretched hands. Most of the injuries produce pain and mild swelling on the radial (thumb side) of the wrist, but any part of the wrist may be in pain. Typically, fractures will swell and hurt more, but that’s not always the case.

X-rays are often needed to differentiate between a fracture and a sprain. If the X-rays are negative, then wrist braces may be worn for comfort and a quick return to sports will be allowed. Most mild sprains heal within two to four weeks, but more significant sprains may take four to six weeks before your child can return to normal function.